Johnson County Empowerment Car Seat/Pack N Play Application
Q1. Who is eligible?
Families with children age 0-5 years and incomes less than 200% of the federal poverty level who live in Johnson County Iowa without a safe child car seat and who have not previously received a car seat or pack n play for this child from Johnson County Empowerment/Early Childhood Iowa.

Q2. What kinds of seats are available?
Rear-facing infant seats, convertible seats that are rear- and front-facing, 5-point harness seats for toddlers, and/or high-back boosters for preschoolers. Infant seats typically last only one year and families may only receive 1 seat per child.

Q3. How do I get the seat?
Once we receive your application and you reach the top of our wait list we will reach out to determine how we can connect you with a car seat technician to get the car seat installed. For prenatal moms this may be at a prenatal medical appointment. For all others this could be at a fire station, car seat clinic, or WIC appointment.

Q4. How long does it take?
It can take a few months to get a seat depending on who is doing the car seat installation.

Q5. How do I get a pack n play?
Once we receive your application and you reach the top of our wait list we will contact you to arrange a time for you to pick up the pack n play or for us to deliver it to you. We always provide safe sleep education along with the pack n play.
Parent/Caregiver 1
Parent/Caregiver 1 Last Name *
Parent/Caregiver 1 First Name *
Address *
Phone *
Email *
Currently Enrolled In (choose all that apply) *
Required
Total number of family members living in the household
Check all sources of Income that parent/caregiver 1 receives (only if not enrolled in any of the above programs)
Parent/Caregiver 2
Parent/Caregiver 2 Last Name
Parent/Caregiver 2 First Name
Phone
Email
Check all sources of Income that parent/caregiver 2 receives
Child 1
Child 1 Name (first and last) *
Child's 1 Birth Date or Due Date *
MM
/
DD
/
YYYY
Child 1 Weight
Child 1 Needs Pack N Play?
Child 1 Has Seat Now?
Child 1 Needs Seat? *
Required
Why Child 1 Needs a Seat
Clear selection
Child 2
Child 2 Name (first and last)
Child's 2 Birth Date or Due Date
MM
/
DD
/
YYYY
Child 2 Weight
Child 2 Needs Pack N Play?
Child 2 Has Seat Now?
Child 2 Needs Seat?
Why Child 2 Needs a Seat
Clear selection
Child 3
Child 3 Name (first and last)
Child's 3 Birth Date or Due Date
MM
/
DD
/
YYYY
Child 3 Weight
Child 3 Needs Pack N Play?
Child 3 Has Seat Now?
Child 3 Needs Seat?
Why Child 3 Needs a Seat
Clear selection
Child 4
Child 4 Name (first and last)
Child's 4 Birth Date or Due Date
MM
/
DD
/
YYYY
Child 4 Weight
Child 4 Needs Pack N Play?
Child 4 Has Seat Now?
Child 4 Needs Seat?
Why Child 4 Needs a Seat
Clear selection
How did you hear about this program?
Signature (type your name) *by signing below I am verifying that the above information is accurate and complete. *
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